The following answers were provided by the content developers of the 2010-2011 AAFP Live! program.
This was successfully posted to your pofile.
This box will close automatically in a few seconds. Close this window
We don't have an e-mail address on file for you. To use AAFP Connection, you must have an e-mail address in our records. Click Here
Module 1: Assessment and Diagnosis of Diabetes
I understand every Rx is important. So do you recommend starting medications and/or insulin for prediabetes (assuming diet/exercise doesn’t help enough)?
The American Association of Clinical Endocrinologists (AACE) guidelines suggest that pharmacologic management for patients with prediabetes be initiated in order to preserve beta-cell function when the patient’s A1c surpasses 6%. I favor aggressive pharmacologic management of prediabetes based on the results of the SAM Study which demonstrated that patients with 2-hour postprandial glucose levels ranging from 160-180 mg/dL have only 20% of their functional beta-cell capacity remaining. These patients are maximally insulin-resistant and should be treated aggressively during their prediabetes stage.
Abdul-Ghani MA, Tripathy D, DeFronzo RA. Contributions of beta-cell dysfunction and insulin resistance to the pathogenesis of impaired glucose tolerance and impaired fasting glucose. Diabetes Care. 2006 May;29(5):1130-9. Review.
What are the recommendations from various organizations for diagnosing gestational diabetes?
As early in pregnancy as possible, risk assessment for gestational diabetes should be performed as delineated in Table 1. Specific organizations’ criteria for diagnosing gestational diabetes are presented in Table 2. The American College of Obstetricians and Gynecologists has not yet adopted the diagnosis of gestational diabetes using only one abnormal value.1
| Risk Category | Low Risk (must meet ALL criteria) | Greater than low risk but not very high risk | Very high risk |
|---|---|---|---|
| Criteria | • Age |
Does not meet criteria for low risk or very high risk category | • Severe obesity |
| • Normal prepregnant weight | • Prior history of gestational diabetes mellitus or delivery of large-for-gestational-age infant | ||
| • No diabetes in first-degree relative | • Glycosuria | ||
| • No history of abnormal glucose tolerance | • Polycystic ovary syndrome | ||
| •No history of poor obstetrical outcome | • History of type 2 diabetes in first-degree relative | ||
| •Member of ethnic group with low prevalence of diabetes mellitus (ie, Hispanic, African, Native American, South or East Asian, or Pacific Islands ancestry) | |||
| Testing | Not required | At 24 to 28 weeks: | Standard diagnostic testing same as for nonpregnant patients |
| 50 gram 1-hour oral glucose challenge; if abnormal, followed by 100-gram 3-hour challenge | |||
| OR | |||
| 75-gram 2-hour oral glucose challenge |
| Diagnostic Test Oral Glucose Tolerance Test | Recommendation By | Number of Abnormal Test Values to Diagnose Gestational Diabetes |
|---|---|---|
| 100-gram 3- hour if 50-gram 1-hour is abnormal | Carpenter and Coustan4 | Two or more values |
| 75-gram 2-hour | World Health Organization5 | One or more values |
| 75-gram 2-hour | International Association of Diabetes and Pregnancy Study Groups Consensus Panel5 | One or more values |
| 75-gram 2-hour | American Diabetes Association6 | One or more values |
1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol. 2001 Sep;98(3):525-38. |
||
For a pregnant woman with diet-controlled gestational diabetes (normal weight and active), what is the recommended blood sugar monitoring at home?
Patients should check their fasting and 1- or 2-hour glucose levels after each meal.1 There is some evidence through a randomized trial comparing preprandial to 1-hour postprandial glucose measurements that there were significantly lower glycohemoglobin levels, macrosomia, neonatal hypoglycemia and cesarean deliveries in patients with postprandial monitoring.2 Although there are no studies that support any particular frequency of glucose monitoring,3 some studies do support daily glucose monitoring because it appears to reduce potentially adverse outcomes such as macrosomia in women with gestational diabetes, but it has not been demonstrated to reduce perinatal mortality.4
1. Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M; American Diabetes Association. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2003 Jan; 26 Suppl 1:S51-61.
2. de Veciana M, Major CA, Morgan MA, Asrat T, Toohey JS, Lien JM, Evans AT. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. N Engl J Med. 1995 Nov 9;333(19):1237-41.
3. Turok DK, Ratcliffe SD, Baxley EG. Management of gestational diabetes mellitus. Am Fam Physician. 2003 Nov 1;68(9):1767-72. Review. Erratum in: Am Fam Physician. 2004 Mar 15;69(6):1362.
4. Lindsay MK, Graves W, Klein L. The relationship of one abnormal glucose tolerance test value and pregnancy complications. Obstet Gynecol. 1989 Jan;73(1):103-6.
2. de Veciana M, Major CA, Morgan MA, Asrat T, Toohey JS, Lien JM, Evans AT. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. N Engl J Med. 1995 Nov 9;333(19):1237-41.
3. Turok DK, Ratcliffe SD, Baxley EG. Management of gestational diabetes mellitus. Am Fam Physician. 2003 Nov 1;68(9):1767-72. Review. Erratum in: Am Fam Physician. 2004 Mar 15;69(6):1362.
4. Lindsay MK, Graves W, Klein L. The relationship of one abnormal glucose tolerance test value and pregnancy complications. Obstet Gynecol. 1989 Jan;73(1):103-6.
Is there an algorithm for recalculating A1c in the setting of chronic anemia?
No, there is no algorithm. Conditions affecting red blood cell lifespan may alter Hgb A1c levels. Hgb A1c decreases (falsely low) with conditions that shorten red blood cell lifespan such as acute or chronic blood loss, hemolysis, sickle cell anemia, thalassemia, and hereditary spherocytosis.
Arnold JG, McGowan HJ. Delay in diagnosis of diabetes mellitus due to inaccurate use of hemoglobin A1C levels. J Am Board Fam Med. 2007 Jan-Feb;20(1):93-6. Erratum in: J Am Board Fam Med. 2007 May-Jun;20(3):326.
Does thalassemia minor affect A1c value interpretation?
Conditions affecting red blood cell lifespan may alter Hgb A1c levels. Hgb A1c decreases (falsely low) with conditions that shorten red blood cell lifespan such as acute or chronic blood loss, hemolysis, sickle cell anemia, thalassemia, and hereditary spherocytosis.
Arnold JG, McGowan HJ. Delay in diagnosis of diabetes mellitus due to inaccurate use of hemoglobin A1C levels. J Am Board Fam Med. 2007 Jan-Feb;20(1):93-6. Erratum in: J Am Board Fam Med. 2007 May-Jun;20(3):326.
Is an A1c goal of <7% always the goal? In other words, in certain populations, is a goal of <8% or <9% acceptable?
Target Hgb A1c >7% may be considered for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or longstanding diabetes uncontrolled despite multiple treatment modalities including insulin.
Skyler JS, Bergenstal R, Bonow RO, Buse J, Deedwania P, Gale EA, Howard BV, Kirkman MS, Kosiborod M, Reaven P, Sherwin RS; American Diabetes Association; American College of Cardiology Foundation; American Heart Association. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care. 2009 Jan;32(1):187-92. Epub 2008 Dec 17. Erratum in: Diabetes Care. 2009 Apr;32(4):754.
Could you comment regarding effectiveness of the low glycemic index diet?
Brand-Miller, et al (Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low-glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials. Diabetes Care. 2003 Aug;26(8):2261-7) evaluated 14 small studies comprising only 356 subjects using low glycemic index diets who had either type 1 or type 2 diabetes. Low glycemic index diets reduced the A1c by 0.43% on average in comparison with high glycemic index diets. This is a very small yet statistically significant improvement in A1c. Low glycemic index diets appear to minimize spikes in postprandial glucose (PPG) levels. Therefore, for patients who are reluctant to begin any type of pharmacologic intervention for type 2 diabetes, use of a low glycemic index diet might be considered an appropriate intervention. However, as beta-cell function declines overtime, PPG levels are likely to increase, and low glycemic index foods are less likely to have an impact. This is because patients will become more insulin-resistant as fasting hepatic glucose production increases while peripheral glucose utilization declines.
Unger J, Parkin CG. Type 2 diabetes: an expanded view of pathophysiology and therapy. Postgrad Med. 2010 May;122(3):145-57. Review.
FAQs
Module 1: Assessment and Diagnosis of Diabetes
Module 2: Diabetes Treatment and Interventions
Module 3: Pharmacologic Management of Diabetes
Module 4: Cardiometabolic Risk in Diabetes
Module 5: Hypertension and Microvascular Disease in Diabetes
Module 6: Other Populations, Special Situations, and Complications